The Director of Quality Management oversees and mentors staff in the collection, analysis, and reporting of data, facilitating improvement projects, assessing for and implementing risk reduction measures and assessing and coordinating activities related to achieving and maintaining ongoing regulatory compliance. Acts as the organizational point-person for interactions with regulatory agencies and provides facility-wide support for improving work processes, patient outcomes, risk reduction and acts as an educational reference.
POSITION SPECIFIC RESPONSIBILITIES:
§ Oversees the effective development, implementation, and evaluation of the Quality Management Program.
§ Assesses for compliance of regulatory requirements, disseminates information on new regulatory requirements, coordinates making changes to policy/practice related to meeting requirements, including contract review, coordinates accreditation activities and inspections and acts as org contact with regulatory agencies.
§ Assists various services in developing criteria for monitoring performance and following up on findings implementing corrective action plans while providing data-driven information hospital wide.
§ Oversees the medical staff peer review process, reappointment clinical profile reporting, and addressment of disruptive physicians by working closely with the medical staff leadership.
§ Promotes a culture of safety, proactive prevention of risks and infections, and philosophy of continuous improvement.
§ Coordinates the review and investigation of risk claims cases, depositions, gathering of information and keeping senior leaders apprised of such cases through appropriate reporting to senior leadership, medical staff leadership, and corporate leadership as it relates to performance improvement, risk management and infection prevention.
- Coordination and linkage of Performance Improvement, Clinical Quality and Service Excellence, Risk Management, Infection Prevention and Regulatory requirements. This includes the execution of shared processes of MIDAS (Event) reports, ENS (Initial and Follow up) Root Cause Analysis, Failure Mode and Effects Analysis (FMEA), AHRQ Culture of Safety Survey, Patient Safety Council, Patient Safety Alerts, oversight of PSES Member site and Member Workforce Education & Confidentiality Agreements, and needed.
§ Clarifies outcomes from survey data or PI reviews with various services when findings are unclear or noncompliant.
§ Maintains current competency related to Performance Improvement, Risk Management, Patient Safety, and Joint Commission, DHS, local agency C MS Regulations.
§ Participates and/or leads team activities toward achieving improvements in performance hospital-wide.
§ Networks with other professionals in the field.
§ Maintains confidentiality of information.
§ Establishes and maintains effective working relationships with customers, i.e. peers, staff, medical staff, and public agencies, etc.
§ Promotes a culture of safety, proactive prevention of risks and infections, and patient-centered care philosophy of continuous improvement.
§ Provides staff education and acts as a facility resource.
MINIMUM ESSENTIAL EXPERIENCE
§ Five (5) years of clinical experience in Quality Management required.
§ Three (3) years leadership experience in Quality Management required.
§ Acute care experience highly preferred.
MINIMUM ESSENTIAL EDUCATION
§ Bachelor's degree in Nursing from an accredited College or University.
§ Master's degree in Nursing, Health Administration or Business Administration preferred.
REQUIRED LICENSURE / CERTIFICATIONS
§ Current license to practice nursing in the state of California
§ Current Basic Life Support (BLS) through the American Heart Association. Must be obtained within 90 days of start date.
§ Specialized professional certification in a related field preferred.
SKILLS AND CERTIFICATIONS [note: bold skills and certification are required]
CA RN license